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PANITIA PELAKSANA KULIAH KERJA NYATA (KKN) UNIVERSITAS HALU OLEO Alamat: Kantor UPT MKU (Eks. orks!o") Kam"#s $#m% Tr%&!arma' An&#ono!# K n&ar% * *+ ,a- ( / +) * *+ ,ORMULIR PEN0A,TARAN MAHASISA PESERTA KULIAH KERJA NYATA (KKN) SEMESTER 1ENAP T.A 2 +/32 +4 UNIVERSITAS HALU OLEO ,AKULTAS:..................................................................... 1. Nama Mahasiswa:.......................................................... 2. Stambuk:................................................................ 3. Jurusan:................................................................ 4. Program Studi:.......................................................... 5. TempatTg!"ahir:....................................................... #. Jenis $e!amin:........................................................... %. Nama &rang Tua'a!i:.................................................... (. )!amat di $endari:....................................................... *. +aerah )sa! a. Pro,insi:............................................................... b. $abupaten:.............................................................. -. $e-a matan:............................................................. d. +esa$e!urahan:......................................................... 1 . )gama:................................................................... 11. Status Nikah/e!um Menikah:.............................................. 12. Peker0aan:............................................................... 13. )!amat $antor:........................................................... 14. Jum!ah mata ku!iah ang be!um di!u!uskan:................................ 15. Jum!ah S$S ang te!ah di!u!uskan:....................................... 1#. P$ $umu!ati :.......................................................... 1%. No T!p. umah6P:....................................................... 1(. 7mai!:................................................................... +engan ini sa a men atakan akan memenuhi sega!a peraturan dan kebi0akan ang ber!aku pa Semester 8enap T.) 2 142 15. $endari9 2 15 Mahasiswa ang /ersangkutan Stambuk :............. 1. ormu!ir disetor pada kantor ;PT. M$; dan dikirim ke<emai! : ahbuddinbudin= ahoo.-o.i 2. )ngkatan 2 11 kebawah memba ar bia a penda taran sebesar p. 3 . . kepenge!o!aan k /"; ;6& /ank /TN No. ekening 1*. 1.3 . 14*.2 3. )ngkatan 2 12 keatas tidak memba ar penda taran. 3 > 4

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